Significant Medication Error Due to Timing of Blood Sugar Check
Penalty
Summary
The facility failed to ensure a significant medication error did not occur for a resident reviewed for medications. The resident, admitted with diagnoses including pneumonia, metabolic encephalopathy, diabetes mellitus type II, chronic kidney disease, muscle wasting and atrophy, and dementia, had a medication order for blood sugar checks and insulin administration at specific times. On April 7, 2025, an LPN checked the resident's blood sugar level after breakfast, which was 346, and administered insulin shortly after. The Director of Nursing later stated that blood sugars should be checked before meals to avoid inaccurate readings and potential hypoglycemia if insulin is administered based on post-meal readings. The facility's Medication Pass policy requires medication administration within one hour before and after scheduled times, with documentation for any deviations.